week 5 Flashcards
1
Q
Anatomical differences - kids vs adults
A
- smaller nasal-pharynx, easily occluded with infection
- lymph tissue grows rapidly in early childhood, slowly atrophies in adolescents
- large tongue small mouth easily occluded
- long floppy epiglottis
- larynx and glottis are higher up on the neck increasing risk for aspiration
- cartilage in neck is flexible (when neck is bent airway can collapse)
- diaphragm is main muscle to breath in children, others less developed –/> hard to compensate for edema spasm and trauma
2
Q
Anatomical differences - kids vs adults - nasal parynx
A
- occludes easily when infected
3
Q
Anatomical differences - kids vs adults - lympth tissue
A
grows faster in early childhood, atrophies in adolescents
4
Q
Anatomical differences - kids vs adults - tongue
A
larger tongue, smaller mouth = easily occluded
5
Q
Anatomical differences - kids vs adults - epiglottis
A
long floppy epiglottis –> aspiration
6
Q
Anatomical differences - kids vs adults - larynx and glottis
A
higher up = increased risk for aspiration
7
Q
Anatomical differences - kids vs adults - cartilage in neck
A
flexible –> when neck is bent airway can collapse
8
Q
Anatomical differences - kids vs adults - diaphragm
A
main muscle for breathing (others less developed)
= less able to compensate for edema spasm trauma
9
Q
Airway infant - normal vs edema
A
- normal = 4mm
- edema from sickness = 1mm
- decreased X-sectional area = 75%
10
Q
Respiratory assessment - what to ask (4)
A
- family history of lung disease
- vitals
- audible inspiratory and expiratory breath sounds
- retractions
11
Q
Respiratory assessment - vitals (12)
A
- resp rate is not just a number
- assess rate depth and ease of respirations
- auscultation
- are breath sounds equally bilaterally
- do they go all the way to bases
- do you hear any adventitious sounds = wheezes, fine/course crackles, referred upper airway noise
- how hard is the patient working?
- tachypnea
- patients colour
- cough
- behavioural change
12
Q
Respiratory assessment - audible inspiratory expiratory breath sounds?
A
- stridor - grunting on expiration
- high pitched musical stridor on inspiration –> foreign body aspiration
13
Q
Stridor
A
grunting on expiration
14
Q
High pitched musical stridor on inspiration
A
foreign body aspiration
15
Q
Respiratory assessment - retractions (5)
A
- tracheal tug
- intercostal
- substernal
- subcostal
- scalene retractions
16
Q
Tachypnea
A
- can child articulate without having to catch his breath
- paradoxical breathing/seesaw breathing
17
Q
Patient’s colour - respiratory
A
- mucous membranes or skin colour
- pink pale, cyanotic, mottled
- crying make it better or worse
18
Q
Cough
A
- productive/non-productive
- seal like-croup
- forceful/weak moving secretions or are they pooling
19
Q
Behavioural change - respiratory
A
decrease in LOC
20
Q
Respiratory distress vs failure - airway patency
A
RD = open and maintainable
RF = not maintainable
21
Q
Respiratory distress vs failure - Breathing (3)
A
RD
- tachypenea
- increased effort-decreased effort
- good air movement
RF
- bradypnea
- decreased effort-apnea
- poor to absent air movement
22
Q
Respiratory distress vs failure - circulatory (2)
A
RD = tachycardia, pallar
RF = bradycardia, cyanosis
23
Q
Respiratory distress vs failure - LOC
A
- RD = anxiety, agitation
- RF = lethargy, unresponsiveness
24
Q
Upper airway obstruction - breath sounds
A
- stridor (typically inspiratory)
- barking cough
- hoarseness
25
Lower airway obstruction - breath sounds
- wheezing (typically expiratory)
- prolonged expiratory phase
26
Lung tissue disease - breath sounds
- grunting
- crackles
- decreased breath sounds
27
Disordered control of breathing - breath sounds
normal
28
RSV - goals of nursing care
- suction q1hr for secretions (esp before feeding)
- maintain fluid volume
- CPAP or BIPAP - helps with pressures, open lungs, clear secretion
29
Cystic Fibrosis - goals of nursing care
- complicated genetic condition, growth curves
- life expectancy in Canada vs US is 15 years different
- impacts endocrine, GI, respiratory, reproductive, etc
30
Respiratory case study: 5yo male presents with chronic cough
- cough is productive increased at night
- worse with exercise and upper respiratory infections
- growth normal
- chest x rays normal except for mild hyperinflation
Asthma!!!
31
Asthma - what
- chronic inflammatory disease of airway
- increased 40% in last decade
- typically develops in childhood, 50% before age 3, majority before 8 y/o
32
asthma - challenge with ICU
CAN'T intubate!! lungs are too hyper-inflated
33
Asthma - pathogenesis (6)
- airway inflammation contributing to airflow limitation
- bronchioconstriciton
- edema
- chronic mucus plugging
- airway wall remodeling
- leads to bronchial obstruction
34
Normal airway vs asthmatic airway
- bronchoconstriction due to edema !
- sludgy mucus plugfs
- muscles are constricted
35
challenge with Treating asthma
- ventalin = bronchodilator
- but can only open airways so far... like balloon with elastics on it and trying to blow it up
36
Asthma - physical exam findings (4)
- wheezing
- crackles in lung
- forced expiratory phase
- muscle retractions (often can be normal)
37
Diagnostic studies for asthma
- chest X-ray (will diffuse hyper inflation)
38
Wheezing + asthma (6)
- localized or diffuse airway narrowing or obstruction from larynx to small bronchi
- high pitched whistling sound made while breathing
- associated with difficulty breathing
- presents on expiration or inspiration
- absence of wheezing in asthmatic = improvement of bronchoconstriction, or severe widespread airflow obstruction
- "silent chest" = sign of respiratory muscle fatigue and failure leading to status asthmaticus
39
PRAM scoring (pediatric respiratory assessment measure) - assesses what (5)
- suprasternal retractions
- scalene muscle contractions
- air entry
- wheezing
- oxygen saturation
40
PRAM scoring - suprasternal retractions
absent = 0
present = 2
41
PRAM scoring - scalene muscle contractions
absent = 0
present = 2
42
PRAM scoring - air entry
normal = 0
decreased at base = 1
widespread decrease = 2
43
PRAM scoring - wheezing
absent = 0
expiratory only = 1
expiratory and inspiratory = 2
audible without stethoscope/silent chest = 3
44
PRAM scoring - O2 sat on room air
>95% = 0
92-94% = 1
<92% = 2
45
PRAM scoring - what is a concerning score
6 or higher
46
Asthma treatment - at home (4)
1) bronchodilators (short acting ventolin/salbutamol)
2) leukotriene modifiers (singulair/montelukast)
3) inhaled corticosteroids (fluticasone/Flovent)
4) combination therapy (inhaled steroid and long-acting bronchodilator)
47
Asthma treatment - in hospital (4)
1) Atrovent/Ipratropium bromide (anticholinergic bronchodilator)
2) dexamethasone (systemic steroids)
3) salbutamol nebulizers via IV
4) magnesium sulfate via IV
48
when asthmatics should come in to hospital
puffers ever 4 hours
49
Salbutamol side effect
makes Heart race (tachycardia)
50
Asthma and exercise (5)
- exercise can trigger asthma
- symptoms are worse with cold dry air
- exercise helps lung function better and prevent obesity
- as long as asthma is well controlled and short acting bronchodilator is used before, children with asthma should be able to do sports
- pulmonary function testing best first, then exercise testing
51
Respiratory case: 4 month old infant brought to ER because of lethargy. Physical exam finds
- 24 week preemie with chronic lung disease, patent ductus arteriosus (PDA), apnea of prematurity
- occasional apneic episodes with feeds, desats to 80s and bradycardia
- now 4 months of age (41 weeks gestational age)
- baseline O2 sats are normal
diagnosis - apnea of infancy
52
Apnea of infancy - what (4)
- unexplained episodes of cessation of breathing for 20 seconds or longer, OR a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia
- called apnea of prematurity when present in infant less than 37 weeks gestational age
- usually ceases by 37 weeks post-menstrual age but may persist for several weeks beyond term
- extreme episodes usually cease at 3 weeks post-conceptional age
53
Apparent Life-Threatening Event (ALTE) (5)
- Episode in an infant that is frightening to observer and is characterized by a combo of
- apnea
- colour change
- unresponsive
- change in muscle tone, choking, gagging
54
Prematurity (3)
- preterm infants -= greater risk of extreme apnea episodes
- risk decreases with time, ceasing at approx. 43 weeks post-menstrual age
- in infants with recurrent significant apnea monitoring may be considered
55
Obstructive sleep apnea (what)
- disorder of breathing during sleep characterized by a) prolonged partial upper airway obstruction, and/or b) intermittent complete obstruction that disrupts ventilation during sleep
- combo of structural and neuromuscular factors
- dynamic process
- site of airway collapse in children most often at level of adenoid
56
Prevalence of obstructive sleep apnea (3)
- children all ages
- most common in preschool-aged children (when tonsils and adenoids are largest in r/t underlying airway size
- estimated prevalence rates of approx. 2%
57
Obstructive sleep apnea - high risk populations (5)
- obesity
- downs syndrome
- Prader Willi syndrome
- neuromuscular disease
- craniofacial anomalies
58
Respiratory case -
- 6 y/o female presents to ER after one week nasal congestion adn mild cough, two days ago developed high fevers, chills, increased cough
- ill appearing, tachypneic, febrile
- crackles on exam over right posterior lung fields
- no prior pneumonia or wheezing
- FHx of asthma
- no recent travel out of country
- WBC 35,000
- white-out on X-Ray of right lung
Right upper Pneumonia
59
Pneumonia - what (3)
- inflammation of lung parenchyma
- portion of lung involved in gas transfer
- alveoli, alveolar ducts, respiratory bronchioles
60
Pneumonia - comon cause
- respiratory virus in first years of life
61
pneumonia - risk factors (2)
daycare
cigarette smoking
62
Pneumonia - clinical signs (10)
- shaking chills
- high fever
- cough
- chest pain
- mild URI
- decreased appetite
- abrupt onset high fever
- rusty-coloured sputum
- respiratory distress
- cyanosis
63
Pneumonia - physical exam (6)
- retractions
- dullness to percussion
- tubular breath sounds
- rales
- diminished tactile and vocal fremitus
- decreased breath sounds
64
Pneumonia - lab findings (5)
- leukocytosis with left shift
- WBC <5000/mm3 (poor prognosis)
- ABG: hypoxemia
- bacteremia on blood culture
- positive sputum culture
65
Mild pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)
- temp <38.5
- mild or absent resp distress
- increased RR (but moderately)
- mild or absent retractions
- no grunting
- no nasal falring
- no apnea
- mild SOB
- normal colour
- normal mental status
- normozemia (O2 sat >92 RA)
- normal feeding (infants) no vomiting
- normal HR
- cap refil <2 seconds
66
severe pneumonia clinical features (temp, respirations, mental status, colour, feeding, HR, cap refil)
- temp >38.5
- moderate to severe respiratory distress (infant >70, children >50)
- moderate/severe suprasternal, intercostal, subcostal retractions
- severe difficulty breathing
- grunting
- nasal flaring
- apnea
- significant SOB
- cyanosis
- altered mental status
- hypoxemia <90 percent at RA
- not feeding (infants) S/S of dehydration (older children)
-tachycardia
- cap refil >2 seconds
67
Complications of pneumonia (6)
- empyema (purulent drainage in pleural space)
- pleural effusion
- pericarditis
- meningitis
- osteomyelitis
- metastatic abscesses
68
Treatment of pneumonia - all children (7)
- decision to hospitalize based on severity of illness and home environment
- can often treat as outpatient
- patients with empyema or pleural effusion should be hospitalized
- oxygen
- thoracentesis
- chest tube drainage
- decortication
69
Treatment of pneumonia - neonates (3)
- parenteral antibiotics (ampicilin, gentamicin)
- treat as rule out sepsis
- once stabilized, they can be discharged
70
Respiratory case - 2 month old infant brought to ER with persistant cough and difficulty breathing
- audible stridor, harsh honking cough, suprasternal subcostal cest wall retractions
- Upper Resp Infection symptoms. low grade fever, nontoxic appearing
whooping cough?
71
Stridor - what (3)
- harsh, high-pitched predominantly inspiratory sound produced by partial obstruction of airway, resulting in turbulent airflow
- associated with degrees of difficulty in breating
- usually associated with suprasternal retractions, when severe with intercostal, subcostal, substernal
72
Causes of stridor in infants and children - nasopharynx
- choanal atresia
- thyroglossal cyst
- hypertrophic tonsils
- retropharyngeal or peritonsillar abscess
73
choanal atresia
narrowing of back of nasal cavity c
74
retropharyngeal or peritonsillar abscess
tonsil stones
75
Causes of stridor in infants and children - larynx
- laryngomalcia
- viral croup
- vocal cord paralysis
- laryngeal stenosis
- laryngospasm
- vocal cord dysfunction
76
Laryngomalcia
laryngeal web, cyst, or laryngocele = noisy breathing
falls in, blocks the airway
77
Viral croup
- spasmodic croup
- epiglottitis
78
Causes of stridor in infants and children - trachea
- subglottic stenosis
- hemangioma
- forein body
- tracheomalacia
- bacterial tracheitis
- external compression
79
Acute laryngotracheobronchitis - etiology
- parainfluenza virus 1, 2, 3
- respiratory syncytial virus
- rhinovirus
- influenza virus a
- adenovirus
80
Acute laryngotracheobronchitis - epidemiology
- fall and early winter
- more common in boys
- mostly at night
- duration from hours to days
81
Recurrent (spasmodic croup) (7)
- 6% of children
- not associated with obvious infection
- abrupt onset, usually during sleep
- barking cough, hoarsness, stridor
- usually resolves within hours
- may be a hypersensitivity reaction
- associated with airway hyper-reactivity
82
Epiglottitis - what (5)
- threatening infection
- incidence is 10-40 cases per 1 million
- widespread vaccination against haemophilus influenzae type B and has decreased incidence dramatically
- age 2-4 years
- various organisms can cause it streptococcus pneumoniae, haemophilus parainfluenzae, varicella, etc.
83
Epiglottitis symptoms (6)
- sore throat
- muffling or changes in voice
- difficulty speaking
- high fever
- dysphagia
- drooling
- respiratory distress
84
treating croup
treat with nebulized epi and puffers of epi to help vasoconstrict everything there to open up airway
- q1hr
dexamethozone (kicks in in 4 hours)
85
What is cystic fibrosis (what, prevelance, symptoms, complications)
- genetic disorder impacting CFTR gene
- most common debilitating disease of childhoodd-
- results in thickened secretion of sweat glands, GI tract, pancreas, respiratory tract, exocrine tissues
- complications = obstruction, chronic infection, tissue damage, resp failure
86
Cystic fibrosis - pathophysiology - respiratory (3)
- thickened mucous
- secretions plug tubes in lungs
- difficulty clearing secretions
87
Cystic fibrosis - pathophysiology - pancreas and digestive (3)
- bile ducts, intestinal glands, gal bladder obstructed by mucous
- pancreatic enzyme activity lost
- malabsorption
88
Cystic fibrosis - pathophysiology - integumentary (4)
- sweat glands produce too much chloride
- salty taste of skin
- electrolyte imbalance
- dehydration
89
Cystic fibrosis - pathophysiology - other complications
fertility issues
90
complications of CF (8)
- hemoptysis
- pneumothorax
- bacterial colonization
- intestinal obstruction
- GERD
- diabetes
- portal hypertension
- decreased fertility
91
Diagnosis of cystic fibrosis
- newborn screening panel
92
Presentation of patient with cystic fibrosis (9)
- respiratory infections
- poor weight gain
- pancreatic insufficiency
- "sweat test"
- persistent cough with thick sputum
- foul smelling greasy stools
- malnutrition
- dehydration/electrolyte imbalance
- nasal polyps
93
Non-phamacological orders for patient with CF
- contact isolation
- vitals q12hr
- physiotherapy to mobilize secretions
- CF diet (high fat high protein)
- Pancreatic elastase stool test
- Pulmonary function test
94
Drug therapy for cystic fibrosis (9)
- ANTIBIOTICS - oral, inhaled/nebulized, IV
- bronchodilators (salbutamol, levalbuterol)
- mucous thinners (hypertonic saline, dornase alfa)
- CFTR modulators (ivacaftor, lumacaftor, tezacafter, etc)
- anti inflammatorys (steroids, NSAIDs)
- oral pancreatic enzymes (pancrelipase)
- acid reducing meds (omeprazole)
- stool softener (polyethylene glycol)
- oxygen therapy
95
Goals for cystic fibrosis management (2)
- nutrition management
- airway clearance techniques
96
Cystic fibrosis potential surgeries/procedures (5)
- bowel surgery
- nasal and sinus surgery
- lung transplant
- liver transplant
- non-invasive ventilation
97
Life expectancy - CF
- median survival 50 years old
98
What is dornase alfa used for
enzyme that decreases viscosity of mucus present in the lungs
99
what is salbutamol used for
bronchodilation
100
what is tobramycin
antibiotic used to treat bacterial infections in respiratory tract
101
what is pancrelipase
enzyme med that aids food digestion
102
why do CF patients take vitamin d supplements?
- CF --> decreased metabolism of vit D = defficiency
- promote bone health, improve lung function
103
Omeprazole role
proton pump inhibitor to decrease production of gastric acid
- allow for pancreatic enzymes to function better
104
ursodiol use
- gallstone dissolusion agent
105
piperacillin tazobactam use
antibiotic (penicillin and beta-lactamase inhibitor) to treat bacterial infections
106
SMOFlipid
- a lipid emulsion providing fatty acids to meet metabolic demands
107
Bronchiolitis and Respiratory Syncytial virus - what
- lower respiratory tract infection caused by virus/bacteria = inflammation/obstruction of bronchioles
108
Pathophysiology of RSV (3)
- mucus hyper-secretion
- cell wall thickening
- smooth muscle contraction
109
Diagnosis of RSV
- children under 2, esp infants under 3 months
- chest X ray --> hyperinflation, patchy atelectasis, inflammation
- Labs = enzyme linked immunosorbent assay (ELISA) or immunoflurescent assay
110
Management of RSV (3)
- educate parents and caregivers to reduce exposure and transmission of disease
- hand hygiene
- limit exposure to crowds other children cigarette smoke
111
Treatment of RSV (4)
- humidified O2 (severe)
- hydration (IV/oral)
- nasal suctioning
- fowler's position
112
Meds to treat RSV (4)
- nebulized hypertonic saline
- acetaminophen
- vitamin D
- nebulized salbutamol/ventolin
113
Goals of care - RV (7)
- care for equipment
- med admin
- head to toe (vitals, resp)
- o2 support
- client education
- fluid and nutrition support
- emotional suport
